In a recent article in the British Medical Journal Maurice-Williams & Dunwoody (1988) reported two patients with frontal meningiomas who presented initially to psychiatrists. The correct diagnosis was made in one of them after prolonged, perhaps unnecessary, psychiatric treatment. In the other the diagnosis was made at autopsy. In this case psychiatrists were only briefly involved and neurosurgical referral had been made promptly. The authors, who treat these reports as a cautionary tale, conclude by warning psychiatrists to pay special attention to a number of features in the history and examination of psychiatric patients. In particular we are told that suspicion should arise in the presence of gradual non-remitting symptoms such as irritability, memory loss, self-neglect, dysphasia or incontinence in patients without a previous history of psychiatric disease or clear precipitating factors. They also suggest that we pay attention to the views of relatives when they feel the patient suffers from a physical rather than a psychiatric illness, and emphasise that early diagnosis leads to easier surgical removal and better outcome.

The necessary components of a comprehensive service of local non-institutional forms of care for the seriously mentally ill have been researched separately in pilot trials, but not within integrated programmes for defined populations. Reported outcomes are at least as favourable as for traditional long-term hospital care, but alternative provisions are no less costly. A case manager system may allow co-ordinated formal and informal services to meet the individual needs of chronically ill patients. Poorly integrated programmes will expose discharged patients to disadvantages.

My aim in this lecture is to review a wide range of published studies on the treatment of depression. I want to look at these with one major clinical question in mind: given the range of treatments available, which treatment should be chosen for which patient? In July 1985 a report, published as a special supplement to the American Journal of Psychiatry, called for more research on this topic:

“As the number and diversity of the effective drugs and psychosocial interventions expand, clinicians will increasingly want objective, reliable criteria with which to match the patient to the optimal treatment modality and to monitor the response.” (Institute of Medicine, 1985)

General hospital psychiatry in Britain began in 1728, and thereafter several new voluntary hospitals provided separate wards for lunatics, but none survived beyond the middle of the 19th century. Less severe nervous organic disorder has always been common in the general wards of voluntary hospitals, and was accepted as the responsibility of neurologists and other physicians; all forms of disorder were admitted to the infirmaries of workhouses. During the present century psychiatrists began to take an interest in non-certifiable mental illnesses and in working in general hospitals. Out-patient clinics became more common following the Mental Treatment Act 1930. The growth of general hospital psychiatric units in the last 30 years began amidst controversy, but has received little recent critical attention.

A clinical assessment was made of 145 long-term users of hospital and social-services day psychiatric facilities, and 84 consented to laboratory pathological screening. We recorded data on relevant medical care where that was being provided. Based on clinical assessment, 59 patients (41%) were judged to have medical problems potentially requiring care. Based on pathological screening 39 (44% of those assessed) had unmet needs, and this rating was associated with poor compliance with attendance and treatment plans. Altogether, 12 patients had important unmet needs, mainly for detailed medical investigation, although none required immediate hospital admission. Long-term patients should be medically reassessed and supervised at appropriate intervals.

An assessment of 106 long-stay psychogeriatric in-patients in an East London borough was made using the CAPE and supplementary items in order to obtain a comprehensive picture of their needs; 51 long-stay residents in the care of local authority social services provided a comparison. Patients in hospital were found to be more disturbed, more disabled and more dependent than residents in local authority care.

A total of 101 elderly depressed patients and 85 community residents (matched for age and sex) were interviewed about life events, difficulties, and confiding relationships. Significantly more of the depressed sample reported at least one severe event in the three months before the onset of their illness. Lack of a good confiding relationship was associated with depression in men but not in women. In this relatively affluent Australian sample, life difficulties were rare and, probably as a result, were not significantly associated with depression.

To investigate the relationships between the immune apparatus, major depression, and HPA-axis and noradrenergic activity, the authors measured the lymphocyte stimulation responses to the mitogens phytohaemagglutinin (PHA), pokeweed mitogen (PWM) and concanavalin A (CON A), post-dexamethasone Cortisol (DST) values and 3-methoxy-4-hydroxyphenylglycol (MHPG) excretion in 24-hour urine samples from 48 patients. We found that lymphocyte responses to PHA and PWM in melancholic and psychotic depressives were significantly lower than in minor depressives. The lymphocyte responses to PHA, PWM and CON A showed significantly negative correlations with age, DST results and HRSD score. Responses to PHA were significantly negatively correlated with MHPG excretion. Up to ±33% of the variance in the three mitogenic lymphocyte responses could be explained by canonical correlation with age, DST results and MHPG values.

The prevalence of Huntington's chorea in Grampian region is high at 9.94 per 100 000. The 46 individuals (26 female, 20 male) were ascertained from 98 pedigrees. Difficulties in ascertainment, family studies, sex ratio and use of resources are discussed.

During transcutaneous PCO2 (PtcCO2) monitoring of 15 freely ambulant patients suffering from panic attacks, all the patients experienced a typical attack. Seven were identified as hyperventilators, as PtcCO2 fell to abnormally low levels during the attack. This group could not be distinguished on the basis of either their usual symptoms of panic or the hyperventilation provocation test. There was no apparent association between absolute levels of PCO2 and the nature of symptoms. The anxiety ratings of hyperventilators were lower than those of non-hyperventilators. These data do not support the hypothesis that hyperventilation causes panic attacks or contributes to their severity. Hyperventilation may be better understood as a consequence of panic.

Sixty-seven women were interviewed four weeks after spontaneous abortion. As determined by the Present State Examination, 32 of these women were psychiatric cases. This rate is four times higher than in the general population of women. In each case the diagnosis was depressive disorder, a finding confirmed by scores on three depression rating scales. Many women showed typical features of grief. Depressive symptoms were significantly associated with a history of previous spontaneous abortion, and less so with childlessness.

A psychiatric consultation was requested in 51 in-patient cases of HIV infection. Reasons for referral included counselling, the evaluation of depressive symptoms, and the treatment of delirium. The most common DSM–III diagnoses included: delirium (n = 13), major depressive disorders (n = 12), dementia (n = 5), and adjustment disorders with depressive or anxious mood (n = 5). The psychiatric treatment of patients with HIV infection does not differ fundamentally from that of other medically ill patients with similar psychiatric symptoms. However, the psychiatric treatment of patients with HIV infection can be hampered by the fear of contagion, negative attitudes towards homosexuals and drug users, and overidentification or avoidance reactions.

In rats, neither acute administration of ethanol nor the establishment of ethanol dependence by chronic administration for 28 days produced significant 1H-NMR relaxation changes. However, chronic ethanol intake for six months produced a transient rise in T1, with no change in T2 or water content. The significance of these results for study in man is discussed and a hypothesis is proposed to explain discrepant differences between T1, T2 and water content. It is suggested that T1 change with long-term ethanol exposure is related to altered free/bound water state secondary to cell membrane changes.

Recent clinical studies have identified significant olfactory deficits in several neuropsychiatric disorders, notably Alzheimer's disease and Parkinson's disease. These have correlated with neurochemical and neuropathological studies of the olfactory system. The presence of a specific sensory deficit may be related to the localisation of pathology within the brain. There is a need for incorporation of olfactory testing into routine clinical examination.

A survey was conducted of 47 suicides, 16 failed suicides, and 24 attempted suicides that occurred from Brisbane river bridges over 15 years. Compared with findings from other suicide surveys, subjects of bridge suicides and failed suicides had a much higher rate of schizophrenia (46%), with hallucinations often precipitating the jump. They also had extensive histories of previous self-harm. Those who attempted suicide by jumping had a higher rate of personality disorder (58%) compared with findings from other attempted suicide surveys, and had very extensive histories of previous self-harm which tended to continue beyond the bridge incident. Both groups had histories of extensive previous psychiatric care.

In a general population survey by Gallup in Great Britain of 4148 subjects, 7.7% had taken benzodiazepines within the last year (male:female ratio 106:212). Younger subjects tended to take anxiolytics for shorter periods compared with older subjects, who often took hypnotics chronically. This pattern was most marked among females. Dosage escalation, tolerance, high daily dose usage, and hoarding were not common. A substantial proportion of current users had experienced difficulty in stopping their medication. Withdrawal problems were associated with being older than 45 years and consuming benzodiazepines for over 12 months. This lends support to the idea of benzodiazepine dependency. However, the appropriateness of long-term therapy for chronic symptoms cannot be ruled out.

In a study of the effects of the teaching of the ‘Grammar of Psychotherapy’ Course, 26 subjects were matched with 27 controls. The students were found to have significantly better interviews than the controls as rated by their patients and by independent blind assessment of their audiotapes six months later. There are some trends which were of interest, although not statistically significant.

Aggression and anxiety are among the most common phenomena needing medical control, especially in acute mental disorders. Today we can choose from a confusingly large array of drugs which can quickly control these two kinds of emotional and behavioural disorders. Everyday practice shows that these two groups of symptoms, seemingly so different from one another, can be treated with the same drugs. If we probe more deeply into the matter, we find that the similarities in these effects include not only inhibition of aggressiveness and anxiety but also their enhancement, activation, and provocation. These effects seem to form a regular pattern: those that increase aggressiveness (sympathicomimetics, catecholamines, ‘activating’ antidepressants, psychostimulants, and anti-Parkinsonics (cholinolytics)) also tend to increase anxiety, while those that decrease aggressiveness (beta-blockers, neuroleptics (major tranquillisers), ‘sedative’ antidepressants, minor tranquilisers, hypnotics, analgesics, and anticonvulsants) also tend to decrease anxiety.

The case of a man presenting with paedophilia who has found to be hyperprolactinaemic is described. There is possibly a link between paedophilia and endocrine disorders.

A 27-year-old woman with a post-partum psychosis developed NMS which proved difficult to diagnose because of the organic features of the presenting illness. Possible contributory factors to the development of NMS included exhaustion, a non-specific viral illness, and rapid loading with haloperidol.